Labor - Exam 1 Flashcards
What is the technical definition of labor?
Uterine contractions that bring about demonstrable effacement and dilatation of the cervix
aka must have cervical change
What are the 5 components of the cervical exam when it comes to labor
dilation
effacement
station
consistency
position
What is considered completely dilated?
0-10cm
10cm is complete dilation
What is effacement? How is it measured?
length of the cervix (how thick it is)
Difference between the internal and external cervical os
What is station? How is it measured?
degree of descent of the presenting part of the fetus
Measured in centimeters from the ischial spines and can be measured in thirds
What does a firm cervical consistency equal? What are the different options? What are the different positions?
firm cervix means they are NOT in labor
consistency options: soft, medium and firm
position: anterior, mid position or posterior
In order to diagnosis labor, there MUST BE _____. What are contractions without this?
cervical change
Braxton Hicks contractions= contractions without cervical change
What is the Bishop Score? **What score is important to remember?
used to determine how favorable the cervix is for labor
**score>8 is favorable cervix for labor
Draw the Bishop Score chart
How common is the premature rupture of membranes?
10% of pregnancies
When should all mothers be screen for Group B Strep? What should you do if positive?
> 35 weeks all pregnant women have ano-vaginal swab
PCN before labor
alt: Erythromycin or Clindamycin or Vanc
Why is IV pain medication NOT used in labor?
Can cause nonreassuring fetal status and fetal respiratory depression
_____ is used for pain management during labor. Where is it placed?
regional anesthesia via epidural that is given as an initial bolus then a continuous infusion is started
placed in L3-4 interspace
What are complications with an epidural?
Maternal hypotension
Maternal respiratory depression
Spinal headache
What are the CI for epidural?
Maternal bleeding disorder or use of LMWH within 12h
Patient refusal
______ is used for pain management during a c-section
spinal anesthesia: one time dose directly into the spinal canal
when is a pudenal block used?
Provides perineal anesthesia
Used with operative vaginal deliveries or for extensive perineal repairs after delivery
When is general anesthesia used labor? What are 2 complications?
c section in emergent or urgent settings
maternal aspiration
risk of hypoxia to mother and fetus
If the pt’s Bishop score is less than 5, it may lead to _______ approximately ____ of the time. What else needs to happen?
failed induction
approx 50% of the time.
Bishop Score <5 indicates need for cervical ripening
When a pt’s labor is induced, what does it do to the latent phase of labor?
Latent phase of labor is significantly longer!!
______ help to ripen and dilate the cervix by causing dissolution of collagen bundles and increase water uptake by cells. What are 2 options?
prostaglandins
Cervidil –PGE2, vaginal
Cytotec – PGE1, vaginal or oral
What are the SE of prostaglandins used in the induction of labor? Give the 2 names
Cervidil –PGE2, vaginal
Cytotec – PGE1, vaginal or oral
Tachysystole, fever, vomiting, diarrhea
Uterine rupture
**What are the CI for prostaglandins?
History of cesarean section
myomectomy (peeling tissue from the uterus)
hysterotomy (incision into the uterus)
_____ is given which leads to induce labor by causing the uterus to contract. What is the identical version that is released from the posterior pituitary?
Pitocin
oxytocin
What are the SE of Pitocin?
Tachysystole - >5 contractions in 10 minutes
Uterine rupture (but not as likely as the prostaglandins)
Hyponatremia
Hypotension
Amniotic fluid embolism
What are the 2 CI of pitocin?
Fetal distress
hypersensitivity
What are the 3 non-medication options for induction of labor?
cervical ripening balloon
laminaria
artificial rupture of membranes using a hook
How does the laminaria work? Where else is it commonly used?
Rolled up seaweed that pulls out water and in turn dilates the cervix
used commonly in endometrium ablations
What are the 2 types of operative vaginal delivery? What are the indications?
forceps
vacuum
indications:
Prolonged second stage of labor
Maternal exhaustion
Hasten delivery for fetal compromise
What is the current rate of C-section in the US?
32.4%
What are the 4 stages of labor?
What does the Freidman’s curve represent?
Good guideline for expected progression in labor and helps to determine abnormal labor patterns
What does Zhang labor curve represent?
Labor progresses similarly for multips and primips until 6cm
active phase of labor starts at 6cm, after 6cm multiparas progress much quicker
How long is the first stage of labor for a nulliparous pt? multiparous?
Nulliparous patient: 10-12 hours
Multiparous patient: 6-8 hours
What are the 2 different phases of the first stage of labor?
latent and active
latent: From onset of labor with slow cervical dilation to ~6 cm. Slower phase
active: from 6cm to complete dilation 10cm with a faster rate of cervical change
What are the 3 P’s that factor into the active stage of labor?
Power – uterus
Passenger – fetus
Pelvis – baby has to fit out of
To assess power of uterine contraction, ______ can be used. To assess activity of contractions ______, _____ or ______ can be used
Intrauterine Pressure Catheter
observation of the mother
palpation of the fundus
external tocodynamometry
What frequency is considered adequate labor? Give general and specific options
Generally 3-5 contractions in a 10 minute period is considered adequate labor
OR
Adequate labor > 200 Montevideo units in 10 min (must use IUPC to measure in Montevideo units)
What are 4 different passenger variables that can affect labor?
macrosomia
fetus lying longitudinal, transverse or oblique
What does a compound fetal presentation mean? Funic?
compound: something in front of the baby-arm
funic: umbilical cord
if a baby is funic presentation, what should you do next?
go straight to C-section
What is Leopolds maneuver? What 3 things make it harder?
abdominal palpation to determine
Fetal lie
Estimate fetal weight
Fetal position
Fetal presentation
Difficult if mother is obese, polyhydramnios or multifetal gestation
Any position other than _____ usually results in a cesarean delivery. What is the weight cuttoff?
vertex
Fetus suspected to be greater than 5000 grams -> consider C section
DM: greater than 4500 grams -> consider C section
Small pelvic outlet can result in _________ and can indicate _____
cephalopelvic disproportion
indicates cesarean delivery
_____ is the ideal pelvic structure for having babies.
gynecoid
What is the difference between labor protractions and labor arrest?
Labor protractions – labor progress that is slower than normal
Labor arrest – cessation of labor progress despite best attempts at augmentation
What is active phase arrest of labor? What do you do next?
no progression in cervical dilation in patients who are at least 6-cm dilated with rupture of membranes despite 4 hours of adequate uterine activity or 6 hours of inadequate uterine activity with oxytocin augmentation
c-section
What are the risk factors for umbilical cord prolapse? What do you do next?
Artifical rupture of membranes
Unengaged fetal head
C-section
What is the second stage of labor defined by? What are 2 indications of the second stage?
Characterized by descent of the presenting part through the maternal pelvis and expulsion of the fetus
pelvic/rectal pressure
mother actively pushes
What is molding?
Alteration of the fetal cranial bones to each other as a result of compressive forces of the maternal bony pelvis during labor
What is considered an abnormal length of the second stage of labor? If the mom decides to keep pushing, this increases the risk of what 4 things?
more than 3 hours of pushing in nulliparous individuals and 2 hours of pushing in multiparous individuals
Neonatal acidemia
NICU admission
Third and fourth degree lacerations
Chorioamnionitis
What are the different degrees of perineal lacerations?
What are 5 complications of an episiotomy? What are the 2 variations of an episiotomy?
Increase vaginal bleeding
Increase postpartum pain
Unsatisfactory anatomic results
Sexual dysfunction
Increase risk of infection
midline and mediolateral
What are maternal risk factors for shoulder dystocia?
Fetal macrosomia
Diabetes – overt and gestational
Previous shoulder dystocia
Maternal obesity
Postterm pregnancy
Prolonged second stage of labor
Operative vaginal delivery
What are fetal risk factors for shoulder dystocia? How do you dx it?
Fracture of humerus and clavicle
Brachial plexus injuries
Phrenic nerve palsy
Hypoxic brain injury
Death
Made when routine delivery maneuvers fail to deliver the anterior shoulder
What is McRobert’s maneuver? When is it used?
sharp flexion of maternal hips
for shoulder dystocia
What is Zavanelli’s maneuver?
replace infants head back into the pelvis and do a c-section
What are different options you could possibly do if a baby presents with shoulder dystocia?
Episiotomy
McRoberts maneuver – sharp flexion of maternal hips
Suprapubic pressure
Delivery of posterior shoulder
Symphisiotomy
Zavanelli
What is the 3rd stage of labor? How long does it usually take?
The time from fetal delivery to delivery of the placenta
Usually about 30minutes
What are 3 signs of placental separation?
Lengthening of umbilical cord
Gush of blood
Fundus becomes globular and more anteverted against abdominal hand
How is the placenta delivered?
delivered using one hand on umbilical cord with gentle downward traction while the other hand on abdomen supporting the uterine fundus
_______ is a risk factor if aggressive traction during delivery of the placenta
uterine inversion
What 3 things need to be monitored closely during the 4th stage of labor?
Blood pressure, uterine blood loss and pulse rate must be monitored closely
What are 3 causes that increase risk for postpartum hemorrhage? Which one is MC?
**Uterine atony –Most common cause
Retained placental fragments
Unrepaired lacerations of vagina, cervix or perineum
What is considered a postpartum hemorrhage?
Blood loss >500c in a vaginal delivery or >1000cc in a cesarean delivery
What is the tx for postpartum hemorrhage?
Removal of placental fragments or repair of lacerations
Additional IV access
Type and cross match for blood
Medications for uterine atony: Pitocin, Methergine, Cytotec, Hemabate
What are the 7 cardinal movements of labor?
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation/restitution
- Expulsion
What is considered engagement? Descent?
Passage of the widest diameter fetal presenting part below the plane of the pelvic inlet. The head is said to be engaged if the leading edge is at the level of the ishial spines
Refers to the downward passage of the presenting part through the bony pelvis
Describe what is happening during flexion? What part of the baby’s head has the smallest diameter?
Occurs passively as the head descends due to the shape of the bony pelvis
Complete flexion allows the fetal head’s smallest diameter to fit through the pelvis
subocciptobregmatic diameter
What happens next after flexion?
internal rotation
Rotation of the fetal head from occiput transverse to occiput anterior or posterior position
Occurs passively due to the shape of the bony pelvis
What is happening in the extension phase?
Occurs when the fetus has descended to the level of the vaginal introitus
When occiput is just past the level of the symphysis, the angle of the birth canal changes to upward position
What is happening in external rotation/restitution?
As the head is delivered, it rotates back to its original position prior to internal rotation
Head aligns anatomically with the fetal torso
The release of the passive forces on the fetal head allows it to return to appropriate position
Consider watching this video again, maybe?
https://www.youtube.com/watch?v=q1jmVN3ILpY
what is a normal fetal heart rate? What is considered bradycardia?
110-160 bpm
Fetal HR less than 110
What are 2 common causes of fetal bradycardia?
congenital heart block: mothers who have Lupus
maternal hypotension
What is considered tachycardia in a fetus? What are 2 common causes?
fetal HR above 160bpm
infection
terbutaline
How do you determine what a fetus’s baseline heart rate is? What about a fetus’s heart rate would make you worry?
Mean bpm over a 10 minute window
absence of variation and greater than 25 bpm of variation
some variation is normal!
What is considered normal fetal heart rate accelerations that is a good thing?
> 32 weeks: at least 15bpm and lasting 15s
<32 weeks: at least 10bpm and lasting 10s
What type of decelerations is normal and is completely fine? What will they look like when compared to the contractions? What is the tx?
Early decelerations
Begin and end approximately at the same time as contractions
no intervention required
What type of decelerations is a problem? What will they look like when compared to the contractions? What is happen? What is the tx?
Late decelerations
Begin at peak of contraction and slowly return to baseline after the contraction has finished
Result of uteroplacental insufficiency (not enough reserve to keep the babies HR up during the contraction)
Position, Oxygen, Stop Pitocin, Check cervix, Fluid Bolus
Consider assisted delivery or cesarean delivery with more than 50% of the contractions
If the FHR deceleration is due to cord compression, what should you do?
amnioinfusion of saline into the amniotic sac
What type of deceleration?
early
dips are happening at the same time as contraction
HR is the top strip and contractions strip is on the bottom
What type of deceleration?
early
What type of deceleration?
late
What type of deceleration?
late
contraction, then heart tone does down
What type of deceleration?
variable
will look like “V” shaped
What type of deceleration? What is the MC cause?
Sinusoidal
fetal anemia
VERY BAD!! need to delivery immediately
What are the different categories of fetal heart rate tracings?
What is the contraction stress test? What do you use? When do you preform this test?
Evaluates the fetal response to a transient reduction in fetal oxygen delivery during uterine contractions
Use pitocin to achieve 3 contractions in 10 minutes
Evaluate fetal status before induction of labor
What is considered a positive (bad), equivocal or negative contraction stress test?
